The collarbone: pro versus you
“The common crack”… you see a crash, then the reaction from the rider. If they land with a thud, so often they reach for their shoulder. Snap! Another collarbone. A couple of weeks off the road, some home trainer action and, oddly, back racing within a few weeks. Professional cyclists get back into action much faster than the average rider… and with good reason. Orthopaedic physio Craig Lennox explains why.
This article was first published in RIDE #59 (March 2013).
Your body: the collarbone break
The nature of a cycling crash means the collarbone is often the part of a body to break in an accident. For elite cyclists the solution is usually surgery but this is based on a a risk-vs-benefit assessment and it may not apply to all, as an orthopaedic physio explains…
– By Craig Lennox
If you are reading this magazine there is a good chance you, or someone you know, has had a broken collarbone. Whether it is a crash at a local club race or the WorldTour, there is always a nervous wait for those watching to see if anyone is hunched on the road nursing an arm; a broken clavicle a common diagnosis. If we compare a club rider and a professional after that initial accident we will find that, despite frequent similarity of injury, their recoveries and return to riding will differ significantly.
Anyone following pro cyclists on Twitter will know that most riders at the top level have surgery within a few days of injury, are back riding the rollers soon after the accident, and are ready to race in a little over a month. But for many it can be two months or more before being allowed to even touch our beloved bicycles, and even more time before we regain the level of fitness we worked so hard to reach.
It seems so unfair, so why is this the case?
A brief anatomy lesson will be helpful at this point. The collarbone, or ‘clavicle’, is a long, thin bone lying between the sternum in the middle of the chest and a lumpy part of the shoulder blade (scapula) called the ‘acromion’. The clavicle is not a straight bone; it curves outwards near the chest and inwards closer to the shoulder. Its job is to be a strut, maintaining the position of the scapula, with which it forms the “shoulder girdle”, which in turn keeps the shoulder joint out and away from the body, maximising the shoulder’s movement.
It is this exposed position of the shoulder, and the arm as a whole, combined with the clavicle’s role as a strut that makes it so easy to break the clavicle when falling from a bike. Whether a fall is onto the shoulder directly or an outstretched hand, much of the energy from the impact will eventually be transmitted through the clavicle. The curves of the bone then result in most fractures being in its middle third, at the junction of the two curves.
So after sustaining a typical mid-shaft clavicular fracture, what happens?
A broken wrist (hopefully not resulting from the same accident) is often treated with a cast. The lower part of the arm and the wrist are encased in a rigid material which keeps the broken bones in position and prevents movement of nearby joints, allowing the fractures to heal. It is, however, impossible to plaster a collarbone, as the bone cannot be completely encased, and to stop shoulder movement a cast would need to cover a very large proportion of the upper body.
That leaves two options: immobilise the shoulder in as practical and comfortable a way as possible and leave the break to hopefully heal itself, or fix the break surgically with scalpels, drills, and plates, pins or nails.
An orthopaedic surgeon looks at an X-ray of a fractured clavicle to see where the break is, if the pieces of bone have moved to cause a deformity, and if the break is likely to be stable or not. If the pieces of bone are unlikely to move, and the deformity is small (roughly 15mm or less), most surgeons choose to leave the fracture to heal with the arm immobilised in a sling. Even with a significant deformity a fracture can heal well, with minimal or no effect at all on the function of the shoulder. If the fracture is healing well, the pain will begin to settle by around two weeks after the break, and the injured cyclist will be able to begin to gently move the shoulder. Riding the trainer may be possible at four weeks, but keeping off the bike until at least six weeks is recommended, as any fall – even a firm bump – carries the risk of re-breaking the still-healing fracture.
If the fracture is unstable, complicated or the pieces have moved significantly, then often a surgeon will recommend surgery in order to put everything back where it should be, hold it all together and hopefully help the bone heal well.
There are various different methods used to hold these fractures together. A plate slid in along the surface of the bone then held in place with several screws is common, or a nail can be put into the middle of the bone. After a repair surgeons will still usually recommend some time in a sling, and to avoid activities which could result in falls (cycling) for at least six weeks, as with the non-surgical option.
Each of these options has its benefits and problems, and it is up to the surgeon to weigh these up and apply them to each case. The fracture itself, as well as the patient’s age and functional ability, need to be considered. Treatment without surgery means that any potential instability in the fracture can result in worsening deformity, or even the bone not healing, possibly resulting in surgery eventually being required anyway and a long recovery. It can also change the biomechanics of the shoulder and impair shoulder function.
Surgical treatment of the break usually results in neater healing of the bone and a lower chance of changed shoulder function. More deformed or unstable breaks can have a better chance to heal well with surgical treatment.
Every general anaesthetic and surgical procedure has risks, including lung and heart problems, blood clots, and infection. The proximity of the clavicle to major organs, blood vessels and nerves can turn small mistakes into major problems. Deaths have occurred from damage to blood vessels near the clavicle during surgery. Each method of fracture fixation also has its problems. Some older style nails have become unpopular as there is evidence of an increased likelihood of problems, and plates sometimes need to be removed as they can cause breakdown of the skin from underneath. With non-surgical treatment in a sling these risks are able to be avoided. Many surgeons will choose not to operate if possible.
Fabian Cancellara, David Millar and Matt Lloyd all suffered broken collarbones from falls last season; all three were back on their bikes and training within a few days, and they were racing at the top level again after only a couple of months. How is it that these professionals can be racing again in the same time it takes for the rest of us to get the OK from a doctor to start gently rolling a few kilometres on the flat (“but it would be better if you waited another month or so”)?
To put it simply, it again comes down to risk versus benefit. But this time the risks of surgery are outweighed by the benefits of the athlete pulling on a jersey with their sponsors’ names across their chest, getting back on their bike and into a big important race with television cameras pointing at them. They are paid lots of money to do this, so there’s an obvious benefit. It is in both the rider’s and their team’s interests to ride again as soon as possible. This is why within a few hours of the fall they are being X-rayed, and within days (or a few more hours) they are being operated on by a top orthopaedic surgeon. A few more days and they’re on the rollers.
What needs to be remembered is that the same risks apply to the professionals as to the rest of us. They risk infection and all other potential problems already mentioned by having surgery. They risk slowed healing from riding their bike and potentially putting too much weight through their arm too early. And they risk falling again and re-breaking their still-fragile clavicle all over again.
Also important is that the surgical techniques used on the professionals are the same as those used for amateurs. There are no special risk-reducing methods for getting professionals riding again quicker. Fabian Cancellara’s break, for example, was fixed with an older style of nail used often a few years ago but no longer popular with many surgeons in Australia.
So if you are ever one of the unlucky ones sitting on the side of the road after a crash, nursing your arm after everyone else is up and riding again, don’t stress too much. Your fractured collarbone will more than likely heal well and in a way which gives you a shoulder that works properly and gets you on the bike again, even if it does take a while. And when you’re sitting on the couch being jealous of the pros who are back in the peloton and racing like nothing happened, you can also be glad that you are giving yourself the best chance of a full recovery, of getting yourself fit again, and of getting back to your favourite weekend loops, bunch rides and races.
– By Craig Lennox
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RIDE Media publishes both the Official Tour de France Guide (Australian Edition) as well as RIDE Cycling Review, a quarterly magazine all about cycling.
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